Monday, 20 July 2015

Complex Post-Traumatic Stress Disorder (C-PTSD) - Complex Post-Traumatic Stress Disorder is a psychological injury that results from prolonged exposure to social or interpersonal trauma, disempowerment, captivity or entrapment, with lack or loss of a viable escape route for the victim.

C-PTSD Introduction

Note: Out of the FOG provides information and support for those with a family member or loved-one who suffers from a personality disorder. This page was written to describe how C-PTSD affects people in relationships with personality-disordered individuals. We welcome visitors who suffer from C-PTSD due to other kinds of trauma. However, please note that we are not a general C-PTSD or PTSD support site. See the links at the bottom of the page for general PTSD & C-PTSD information.

Complex Post Traumatic Stress Disorder (C-PTSD) is a condition that results from chronic or long-term exposure to emotional trauma over which a victim has little or no control and from which there is little or no hope of escape, such as in cases of:

When people have been trapped in a situation over which they had little or no control at the beginning, middle or end, they can carry an intense sense of dread even after that situation is removed. This is because they know how bad things can possibly be. And they know that it could possibly happen again. And they know that if it ever does happen again, it might be worse than before.

The degree of C-PTSD trauma cannot be defined purely in terms of the trauma that a person has experienced. It is important to understand that each person is different and has a different tolerance level to trauma. Therefore, what one person may be able to shake off, another person may not. Therefore more or less exposure to trauma does not necessarily make the C-PTSD any more or less severe.

C-PTSD sufferers may "stuff" or suppress their emotional reaction to traumatic events without resolution either because they believe each event by itself doesn't seem like such a big deal or because they see no satisfactory resolution opportunity available to them. This suppression of "emotional baggage" can continue for a long time either until a "last straw" event occurs, or a safer emotional environment emerges and the damn begins to break.

The "Complex" in Complex Post Traumatic Disorder describes how one layer after another of trauma can interact with one another. Sometimes, it is mistakenly assumed that the most recent traumatic event in a person's life is the one that brought them to their knees. However, just addressing that single most-recent event may possibly be an invalidating experience for the C-PTSD sufferer. Therefore, it is important to recognize that those who suffer from C-PTSD may be experiencing feelings from all their traumatic exposure, even as they try to address the most recent traumatic event.

This is what differentiates C-PTSD from the classic PTSD diagnosis - which typically describes an emotional response to a single or to a discrete number of traumatic events.

C-PTSD results more from chronic repetitive stress from which there is little chance of escape. PTSD can result from single events, or short term exposure to extreme stress or trauma.

Therefore a soldier returning from intense battle may be likely to show PTSD symptoms, but a kidnapped prisoner of war who was held for several years may show additional symptoms of C-PTSD.

Similarly, a child who witnesses a friend's death in an accident may exhibit some symptoms of PTSD but a child who grows up in an abusive home may exhibit the additional C-PTSD characteristics shown below:

C-PTSD - What it Feels Like:

People who suffer from C-PTSD may feel un-centered and shaky, as if they are likely to have an embarrassing emotional breakdown or burst into tears at any moment. They may feel unloved - or that nothing they can accomplish is ever going to be "good enough" for others.

People who suffer from C-PTSD may feel compelled to get away from others and be by themselves, so that no-one will witness what may come next. They may feel afraid to form close friendships to prevent possible loss should another catastrophe strike.

People who suffer from C-PTSD may feel that everything is just about to go "out the window" and that they will not be able to handle even the simplest task. They may be too distracted by what is going on at home to focus on being successful at school or in the workplace.

Learned Helplessness- Learned helplessness is when a person begins to believe that they have no control over a situation, even when they do.

Low Self-Esteem - A common name for a negatively-distorted self-view which is inconsistent with reality.

Panic Attacks - Short intense episodes of fear or anxiety, often accompanied by physical symptoms, such as hyperventilating, shaking, sweating and chills.

Perfectionism - The maladaptive practice of holding oneself or others to an unrealistic, unattainable or unsustainable standard of organization, order, or accomplishment in one particular area of living, while sometimes neglecting common standards of organization, order or accomplishment in other areas of living.

Self-Loathing - An extreme hatred of one's own self, actions or one's ethnic or demographic background.

Tunnel Vision - The habit or tendency to only see or focus on a single priority while neglecting or ignoring other important priorities.

C-PTSD Causes

C-PTSD is caused by a prolonged or sustained exposure to emotional trauma or abuse from which no short-term means of escape is available or apparent to the victim.

The precise neurological damage that exists in C-PTSD victims is not well understood.

C-PTSD Treatment

Little has been done in clinical studies of treatment of C-PTSD. However, in general the following is recommended:

Removal of and protection from the source of the trauma and/or abuse.

Acknowledgement of the trauma as real, important and undeserved.

Acknowledge that the trauma came from something that was stronger than the victim and therefore could not be avoided.

Acknowledgement of the "complex" nature of C-PTSD - that responses to earlier traumas may have led to decisions that brought on additional, undeserved trauma.

Acknowledgement that recovery from the trauma is not trivial and will require significant time and effort.

Separation of residual problems into those that the victim can resolve (such as personal improvement goals) and those that the victim cannot resolve (such as the behavior of a disordered family member)

Mourning for what has been lost and cannot be recovered.

Identification of what has been lost and can be recovered.

Program of recovery with focus on what can be improved in an individual's life that is under their own control.

Placement in a supportive environment where the victim can discover they are not alone and can receive validation for their successes and support through their struggles.

As necessary, personal therapy to promote self-discovery.

As required, prescription of antidepressant medications.

What to do about C-PTSD if you've got it:

Remove yourself from the primary or situation or secondary situations stemming from the primary abuse. Seek therapy. Talk about it. Write about it. Meditation. Medication if needed. Physical Exercise. Rewrite the script of your life.

What are bipolar disorder symptoms and signs in adults, teenagers, and children?

How is bipolar disorder diagnosed?

What illnesses coexist with bipolar disorder?

What are bipolar disorder medications and other treatments? Are there any home remedies or alternative treatments for bipolar disorder?

How is bipolar disorder treated during pregnancy and the postpartum period?

What are complications and the prognosis/effects over time of bipolar disorder?

Can bipolar disorder be prevented?

Where can people find more information about bipolar disorder?

Where can people find support to help them or someone they know cope with bipolar disorder?

Bipolar Disorder (Mania) FAQs

Bipolar disorder facts

Bipolar disorder, also commonly called manic depression, is characterized by mood swings and repeated episodes of depression with at least one episode of mania.

Bipolar disorder afflicts up to 4 million people in the United States and is the fifth leading cause of disability worldwide.

The suicide rate for people with bipolar disorder is 60 times higher than in the general public.

Bipolar disorder was conceptualized by Emil Kraeplin more than 100 years ago, but its symptoms were first described as long ago as 200 A.D.

Bipolar disorder has a number of types, including bipolar I and bipolar II disorder based on the severity of symptoms, and may be described as mixed or rapid cycling based on the duration and frequency of episodes.

As with most other mental disorders, bipolar disorder is not directly passed from one generation to another genetically but is thought to be the result of a complex group of genetic, psychological, and environmental factors.

The adolescent with bipolar disorder is more likely to exhibit depression and mixed episodes, with rapid changes in mood.

Symptoms of bipolar disorder in women tend to include more depression and anxiety as well as a rapid-cycling pattern compared to symptoms in men.

Since there is no one test that definitively indicates that someone has bipolar disorder, health-care professionals diagnose this disease by gathering comprehensive medical, family, and mental-health information in addition to performing physical and mental-health evaluations.

Treatment of bipolar disorder with medications tends to relieve already existing symptoms of mania or depression and prevent symptoms from returning.

Talk therapy (psychotherapy) is an important part of helping individuals with bipolar disorder achieve the highest level of functioning possible.

When treating individuals with bipolar disorder who are pregnant or nursing, health-care professionals take great care to balance the need to maintain the person's stable mood and behavior while minimizing the risks that medications used to treat this disorder may present.

What is bipolar disorder?

Bipolar disorder, also called manic depression, is a mental illness that is characterized by severe mood swings, repeated episodes of depression, and at least one episode of mania. Bipolar disorder is one kind of mood disorder that afflicts more than 1% of adults in the United States, up to as many as 4 million people. Here are some additional statistics about bipolar disorder:

Bipolar disorder is the fifth leading cause of disability worldwide.

Bipolar disorder is the ninth leading cause of years lost to death or disability worldwide.

The number of individuals with bipolar disorder who commit suicide is 60 times higher than that of the general population.

People who have bipolar disorder are at a higher risk of also suffering from substance abuse such as alcoholism as well as other mental-health problems.

Males may develop bipolar disorder earlier in life compared to females.

Blacks are sometimes diagnosed more often with bipolar disorder compared to whites.

What is the history of bipolar disorder?

This disease was formally conceptualized by Emil Kraeplin more than 100 years ago, at which time he described it as manic-depressive insanity. However, mood problems that include depression alternating with symptoms that are now understood to be manic have been referenced in history as long ago as 200 A.D. At that time, this illness, like unipolar depression, was thought to be the result of bad blood, called black bile. In the 19th century, this illness was referred to by terms like biphasic illness, circular insanity, and dual-form insanity. Despite such unfortunate terminology for this disease, bipolar disorder is also known to be associated with significant achievement in some individuals. Many historical figures and current luminaries suffer from this disorder, whose creativity and accomplishments can therefore be an inspiration for current sufferers of bipolar disorder.

What are the types of bipolar disorder?

Bipolar disorder has a number of types, including bipolar I and bipolar II disorder. Depending on how rapidly the mood swings occur, the episodes of bipolar disorder can also be classified as having mixed (mood disordered episodes that last less than the usual amount of time required for the diagnosis) features or rapid cycling (four or more mood disordered episodes per year) features. About two-fifths of people with bipolar disorder have at least one period of rapid cycling over the course of their lifetime. For every type and duration of the illness, the sufferer experiences significant problems with his or her functioning at school, at work, or socially, may require hospitalization, or may have psychotic symptoms (for example, delusions or hallucinations). The diagnosis of bipolar I disorder requires that the individual has at least one manic episode but does not require a history of major depression. Bipolar II disorder is diagnosed if the person has experienced at least one episode of major depression and at least one episode of hypomania (a milder form of mania).

Mixed features are defined as meeting full diagnostic criteria for a manic episode while also suffering from at least three symptoms of a depressive episode, or meeting full diagnostic criteria for a major depressive episode while also suffering from at least three symptoms of a manic or hypomanic episode. People who suffer from significant, debilitating seasonal mood changes year after year may be classified as having a seasonal pattern to their bipolar disorder.

What are bipolar disorder causes and risk factors?

One frequently asked question about bipolar disorder is if it is hereditary. As with most other mental disorders, bipolar disorder is not directly passed from one generation to another genetically. Rather, it is the result of a complex group of genetic, psychological, and environmental factors. Genetically, bipolar disorder and schizophrenia have much in common, in that the two disorders share a number of the same risk genes. However, both illnesses also have some genetic factors that are unique.

Stress has been found to be a significant contributor to the development of most mental illnesses, including bipolar disorder. For example, gay, lesbian, and bisexual people are thought to experience increased emotional struggles associated with the multiple social stressors that are linked to coping with societal reactions to their homosexuality or bisexuality.

What are bipolar disorder symptoms and signs in adults, teenagers, and children?

In order to qualify for the diagnosis of bipolar disorder, a person must experience at least one manic episode. Characteristics of manic episodes must last at least a week (unless it is part of mixed features) and include

elevated, expansive, or irritable mood;

racing thoughts;

pressured speech (rapid, excessive speech);

decreased need for sleep;

grandiose beliefs (for example, feeling like one has super powers or superlative talents or faults);

Symptoms of the manic episode of early onset bipolar disorder tend to include outbursts of anger and rage, as well as irritability, as opposed to the expansive, excessively elevated mood seen in adults. The adolescent with bipolar disorder is more likely to exhibit depression and mixed episodes with rapid changes in mood. Despite differences in the symptoms of bipolar disorder in teens and children compared to adults, many who are diagnosed with certain kinds of pediatric bipolar disorder continue to have those symptoms as adults. Symptoms of bipolar disorder in women tend to include more depression and anxiety and a rapid cycling pattern compared to symptoms in men.

Although a major depressive episode is not required for the diagnosis of bipolar disorder, such episodes often alternate with manic episodes. In fact, persistent sadness occurs more often than mania in many people with bipolar disorder. Characteristics of depressive episodes include a number of the following symptoms: persistently depressed or irritable mood; decreased interest in previously pleasurable activities; change or problems in appetite, weight, or sleep; agitation or lack of activity; fatigue; feelings of worthlessness; trouble concentrating; thoughts of death or suicidal thoughts, plans, or actions.

How is bipolar disorder diagnosed?

As is true with virtually any mental-health diagnosis, there is no one test that definitively indicates that someone has bipolar disorder. Therefore, health-care professionals diagnose this disease by gathering comprehensive medical, family, and mental-health information. The health-care professional will also either perform a physical examination or request that the individual's primary-care doctor perform one. The medical examination will usually include lab tests to evaluate the person's general health and to explore whether or not the individual has mental-health symptoms like euphoria, depression, and rarely psychosis that are associated with a medical condition.

In asking questions about mental-health symptoms, mental-health professionals are often exploring if the individual suffers from depression and/or manic symptoms but also anxiety, substance abuse, hallucinations or delusions, as well as some personality and behavioral disorders. Health-care professionals may provide the people they evaluate with a quiz or self-test as a screening tool for bipolar disorder and other mood disorders. Since some of the symptoms of bipolar disorder can also occur in other mental illnesses, the mental-health screening is to determine if the individual suffers from bipolar disorder, an anxiety disorder like panic disorder, generalized anxiety disorder, or posttraumatic stress disorder (PTSD). The examiner also explores whether the person with bipolar disorder suffers from other mental illnesses like schizophrenia, schizoaffective disorder, and other psychotic disorders, or a substance abuse, personality, or behavior disorder like attention deficit hyperactivity disorder (ADHD). Any disorder that is associated with sudden changes in behavior, mood, or thinking, like a psychotic disorder, borderline personality disorder, or multiple personality disorder (MPD), may be particularly challenging to distinguish from bipolar disorder. In order to assess the person's current emotional state, health-care professionals perform a mental-status examination as well.

What illnesses coexist with bipolar disorder?

In addition to providing treatment that is appropriate to the diagnosis, determining the presence of mental illnesses that may co-occur (be co-morbid) with bipolar disorder is important in preventing bad outcomes. For example, people with bipolar disorder are at increased risk of committing suicide, particularly after engaging in previous episodes of cutting or other self-harm. Therefore, mental-health-care professionals will take care to examine for any warning signs that the person with bipolar disorder is thinking of harming himself or herself or others. Individuals who suffer from this illness, in addition to either alcohol or substance-abuse problems or borderline personality disorder, are also at particular risk of committing suicide. People with bipolar disorder are at higher risk of having an anxiety disorder like panic disorder, phobias, generalized anxiety disorder, or obsessive compulsive disorder (OCD).

What are bipolar disorder medications and other treatments? Are there any home remedies or alternative treatments for bipolar disorder?

Many people, whether they suffer from bipolar disorder or any medical or other mental illness, understandably wonder how they might help themselves to have the best outcome of treatment. While medications and psychotherapies remain mainstays of treatment of bipolar disorder, lifestyle improvements can be important complementary measures to care for this population. For example, aerobic exercise has been found to help alleviate some of the thinking problems, like memory and ability to pay attention, that are associated with bipolar disorder and other mental-health problems. While some home remedies or alternative treatments like St. John's wort have been found to help mild depression, they may induce a manic episode. There remains insufficient evidence that such treatments successfully treat manic symptoms. Although alternative medicine treatments for bipolar disorder like St. John's wort or ginkgo biloba are not recognized as standard care for bipolar disorder, as many as one-third of some patient groups being treated for this disorder report using them.

Medications

In terms of the overall approach to treatment, people with bipolar disorder can expect their mental-health professionals to utilize several medical interventions in the form of medications, psychotherapies, and lifestyle advice. Treatment of bipolar disorder with medications tends to address two aspects: relieving already existing symptoms of mania or depression and preventing symptoms from returning. Medications that are thought to be particularly effective in treating manic and mixed symptoms include olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), ziprasidone (Geodon), aripiprazole (Abilify), paliperidone (Invega), asenapine (Saphris),iloperidone (Fanapt), and lurasidone (Latuda). These medications belong to a group of medications called neuroleptics and are known for having the ability to work quickly compared to many other psychiatric medications. For this group of medications, side effects that occur most often include sleepiness, dizziness, and increased appetite. Weight gain, which may be associated with elevated blood sugar, elevated lipid levels, and sometimes increased levels of a hormone called prolactin, may also occur. Although older medications in this class that were not mentioned here are more likely to cause muscle stiffness, shakiness, and very rarely uncoordinated muscle twitches (tardive dyskinesia) that can be permanent, health-care professionals appropriately monitor the people they treat for these potential side effects as well.

Mood-stabilizer medications like lithium (Lithobid), divalproex (Depakote), carbamazepine (Tegretol, Tegretol XR, Equetro, Carbatrol), and lamotrigine (Lamictal) can be useful in treating active (acute) symptoms of manic or mixed episodes, as well as preventing the return of such symptoms. These medications may take a bit longer to work compared to the neuroleptic medications, some (for example, lithium, divalproex, and carbamazepine) require monitoring of medication blood levels, and some can be associated with birth defects when taken by pregnant women.

Antidepressant medications are the primary medical treatment for the depressive symptoms of bipolar disorder. Examples of antidepressants that are commonly prescribed for that purpose include serotonergic (selective serotonin reuptake inhibitor or SSRI) medications like fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and escitalopram (Lexapro); there are also combination serotonergic/adrenergic medications (SNRIs) like venlafaxine (Effexor), duloxetine (Cymbalta), and desvenlafaxine (Pristiq), as well as bupropion (Wellbutrin), which is a dopaminergic antidepressant. While antidepressant medication remains a mainstay of treatment for the depression of bipolar disorder, the prescribing physician will remain watchful since there is some concern that antidepressants can induce a manic or near-manic (hypomanic) episode or rapid mood cycling pattern of symptoms.

When using medicines to prevent symptoms of manic or mixed episodes, mood-stabilizer medications like lithium or lamotrigine (Lamictal) are often used. Health-care professionals who prescribe lithium monitor blood levels of the medication to be sure it is within a therapeutic, safe level. The functioning of other body systems is frequently followed to quickly address any abnormal changes that may be associated with the medication. When a neuroleptic like olanzapine is used in combination with lithium, symptoms of relapse may be prevented for a longer period of time compared to when lithium is used alone. While lamotrigine tends to cause few side effects, practitioners tend to question the people they treat closely about symptoms of persistent fever, rash, or sore throat that may be warning signs of a rare but potentially fatal side effect. Depakote is also associated with that rare but potentially dangerous side effect. Medications like topiramate (Topamax) are being researched as a potential treatment for people with bipolar disorder who engage in pedophilia, sexual addiction, or are otherwise considered sexually deviant. While oxcarbazepine (Trileptal) continues to be used by many in an attempt to manage the mood swings of both adult and pediatric bipolar disorder, its effectiveness remains a matter of debate.

Despite its stigmatized history, electroconvulsive therapy (ECT) can be a viable treatment for people whose bipolar disorder has inadequately responded to psychotherapies and a number of medication trials.

Psychotherapies

Talk therapy (psychotherapy) is an important part of helping individuals with bipolar disorder achieve the highest level of functioning possible by improving ways of coping with the illness. These interventions are therefore seen by some as being forms of occupational therapy for people with bipolar disorder. Psychotherapy may also engage people with bipolar disorder who prefer to receive treatment without medication. While medications can be quite helpful in alleviating and preventing overt symptoms, they do not address the many complex social and psychological issues that can play a major role in how the person with this disease functions at work, home, and in his or her relationships. Since about 60% of people with bipolar disorder take less than 30% of their medications as prescribed, any supports that can promote compliance with treatment and otherwise promote the health of individuals in this population are valuable.

Psychotherapies that have been found to be effective in treating bipolar disorder include family focused therapy, psycho-education, cognitive therapy, interpersonal therapy, and social rhythm therapy. Family focused therapy involves education of family members about the disorder and how to provide appropriate support (psycho-education) to their loved one. This intervention also includes communication-enhancement training, and teaching family members problem-solving skills training. Psycho-education involves teaching the person with bipolar disorder and their family members about the symptoms of full-blown depressive and manic symptoms, as well as warning signs (for example, change in sleep pattern or appetite, change in activity level or increased irritability) that the person is beginning to experience either mood episode. In cognitive behavioral therapy, the mental-health professional works to help the person with bipolar disorder identify, challenge, and decrease negative thinking and otherwise dysfunctional belief systems. The goal of interpersonal therapy tends to be identifying and managing problems the sufferers of bipolar disorder may have in their relationships with others. Social rhythm therapy encourages stability of sleep-wake cycles, with the goal of preventing or alleviating the sleep disturbances often associated with this disorder.

How is bipolar disorder treated during pregnancy and the postpartum period?

When treating pregnant or postpartum individuals with bipolar disorder, health-care professionals take great care to balance the need to maintain the person's stable mood and behavior while minimizing the risks that medications used to treat this disorder may present to the patient, developing fetus, or nursing infant. While many medications that treat bipolar disorder may carry risks to the fetus in pregnancy and during breastfeeding, careful monitoring of the amount of medication that is administered as well as the health of the fetus or infant and of the mother can go a long way toward protecting the fetus or infant from any such risks, while maximizing the chance that the fetus or infant will grow in the healthier environment inside or outside the womb afforded by an emotionally healthy mother.

What are complications and the prognosis/effects over time of bipolar disorder?

While the prognosis for bipolar disorder indicates that individuals with this disorder can expect to experience episodes of some sort of mood problem up to 60% of the time, those episodes can be well managed by comprehensive treatment. There are a number of potential complications of bipolar disorder, particularly if left untreated. This illness may be compounded by other mental-health problems including substance abuse and addiction, whether it be to legal substances like alcohol or tobacco, prescription medications like amphetamine and dextroamphetamine (Adderall) or hydrocodone/acetaminophen (Vicodin), or to illicit drugs like heroine or cocaine. The risk of committing suicide is 60 times higher for people with bipolar disorder compared to the general population. That may be partly due to the chronic emotional pain that some people with this disorder experience, in that they endure years of depressive and manic symptoms, the consequences of their actions during those disease states, as well as potentially longing for the increased energy and sense of well-being of mania that may be quelled by psychiatric medications. Bipolar disorder is the fifth leading cause of disability and the ninth leading cause of years lost to death or disability worldwide.

Can bipolar disorder be prevented?

While far more seems to be known about the prevention of symptoms of bipolar disorder following its diagnosis, there is emerging research about ways to attempt to decrease the development of the full-blown disease altogether. For example, when family focused therapy is provided to children who have more subtle symptoms preceding bipolar disorder and who have bipolar relatives, they may be less likely to develop the full-blown disorder as adults.

Dissociative identity disorder (DID) facts

Dissociative identity disorder (DID), formerly called multiple personality disorder, is an illness that is characterized by the presence of at least two clear personality states, called alters, which may have different reactions, emotions, and body functioning.

How often DID occurs remains difficult to know due to disagreement among professionals about the existence of the diagnosis itself, its symptoms, and how to best assess the illness.

DID is diagnosed nine times more often in females than in males.

A history of severe abuse is thought to be associated with DID.

DID has been portrayed in the media in productions like The Three Faces of Eveand Sybil.

Signs and symptoms of DID include time and memory lapses, blackouts, being often accused of lying, finding apparently strange items among one's possessions, having apparent strangers recognize them as someone else, feeling unreal, and feeling like more than one person.

As there is no specific diagnostic test for DID, mental health professionals perform a mental health interview, ruling out other mental disorders, and referring the client for medical evaluation to rule out a physical cause for symptoms.

Individuals with DID often also suffer from other mental illnesses, including posttraumatic stress disorder, borderline and other personality disorders, and conversion disorder.

People who may benefit either emotionally or legally from having DID sometimes pretend to have it, as with those who molest children, have antisocial personality disorder, or in cases of Munchausen's syndrome.

Some researchers are of the opinion that sex offenders who truly suffer from DID are best identified using a structured interview.

Psychotherapy is the mainstay of treatment of DID and usually involves helping individuals with DID improve their relationship with others, preventing crises, and to experience feelings they are not comfortable with having.

Eye movement desensitization and reprocessing (EMDR), a treatment method that integrates traumatic memories with the patient's own resources, is being increasingly used in the treatment of people with dissociative identity disorder.

Hypnosis is sometimes used to help people with DID learn more about their personality states in the hope of their gaining better control of those states.

Although medications can be helpful in managing emotional symptoms that sometimes occur with DID, caution is exercised when it is prescribed in order to avoid making the individual feel retraumatized by feeling controlled.

People with DID may have trouble keeping a job and maintaining relationships and are at risk for engaging in drug and alcohol abuse as well as hurting themselves and others.

What is dissociative identity disorder?

Dissociative identity disorder (DID) is a mental illness that involves the sufferer experiencing at least two clear identities or personality states, also called alters, each of which has a fairly consistent way of viewing and relating to the world. Some individuals with DID have been found to have personality states that have distinctly different ways of reacting, in terms of emotions, pulse, blood pressure, and blood flow to the brain. This disorder was formerly called multiple personality disorder (MPD) and is often colloquially referred to as split personality disorder. Statistics regarding this disorder indicate that the incidence of DID is about 3% of patients in psychiatric hospitals and is described as occurring in females nine times more often than in males. However, this female preponderance may be due to difficulty identifying the disorder in males. Also, disagreement among mental health professionals about how this illness appears clinically, and if DID even exists, adds to the difficulty of estimating how often it occurs.

Some professionals continue to be of the opinion that DID does not exist. The nature of this skepticism is sometimes due to questions about why many more individuals who have endured the stress of terrible abuse as young children do not develop the disorder, why more children are not diagnosed as having DID, and why some DID sufferers have no history of tremendous trauma. One explanation for what some believe to be these inconsistencies is that given the highly complex and unknown nature of the human brain and psyche, many of those whom one would expect to develop dissociative identity disorder are spared due to their resilience. Another concern about the diagnosis of DID involves having to rely on the traumatic memories of those who suffer from this disorder. That DID is significantly more often assessed in individuals in North America compared to the rest of the world, for the most part, leads some practitioners to believe that DID is a culture-based myth rather than a true disorder. As with many other mental health issues, symptoms of the same disorder in children look very different than symptoms in adults. Studies that verify the presence of DID using multiple resources add credibility to the diagnosis. Research on individuals with DID that have little to no media exposure to information on the illness lends further credibility to the reliability of the existence of this mental health condition.

Although there was a case study of DID as early as 1906, movies about DID first became well known in the United States since the 1950s. The 1953 movie The Three Faces of Eve tells the story of Chris Sizemore, a real-life woman with the disorder. She was thought to develop DID in reaction to witnessing several terrible accidents at a young age. That movie described three personalities that were successfully merged or integrated into one within one year. More accurately, the person depicted in that movie reportedly had to contend with 22 personalities that took more than 45 years to be able to coexist in a functional way. A television miniseries about DID was Sybil. The character of Sybil Dorsett portrayed the life story of Shirley Ardell Mason, who experienced severe physical, emotional, and sexual abuse that was inflicted by her mother. She was thought to develop 16 distinct identities. As with the diagnosis in general, the veracity of the story of Sybil remains a controversy, with claims that the illness in general, and Sybil specifically, is a hoax.

What are causes and risk factors of dissociative identity disorder?

While there is no proven specific cause of DID, the prevailing psychological theory about how the condition develops is as a reaction to childhood trauma. Specifically, it is thought that one way that some individuals respond to being severely traumatized as a young child is to wall off, in other words to dissociate, those memories. When that reaction becomes extreme, DID may be the result. As with other mental disorders, having a family member with DID may be a risk factor, in that it indicates a potential vulnerability to developing the disorder but does not translate into the condition being literally hereditary.

What are the signs and symptoms of dissociative identity disorder?

Signs and symptoms of dissociative identity disorder include

lapses in memory (dissociation), particularly of significant life events, like birthdays, weddings, or birth of a child;

experiencing blackouts in time, resulting in finding oneself in places but not recalling how one traveled there;

being frequently accused of lying when they do not believe they are lying (for example, being told of things they did but do not recall, unrelated to the influence of any drug or medical condition);

finding items in one's possession but not recalling how those things were acquired;

encountering people with whom one is unfamiliar but who seem to know them sometimes as someone else;

being called names that are completely unlike their own name or nickname;

finding items they have clearly written but are in handwriting other than their own;

hearing voices inside their head that are not their own;

not recognizing themselves in the mirror;

feeling unreal (derealization);

feeling like they are watching themselves move through life rather than living their own life;

feeling like more than one person.

How is dissociative identity disorder diagnosed?

There is no specific definitive test, like a blood test, that can accurately assess that a person has dissociative identity disorder. Therefore, practitioners conduct a mental health interview that gathers information, looking for the presence of the signs and symptoms previously described.

The diagnostic criteria for dissociative identity disorder are as follows:

The presence of two or more distinct identities or personality states (each with its own relatively persistent pattern of perceiving, relating to, and thinking about him or herself and the world)

At least two of the identities or personality states repeatedly take control of the person's behavior.

Inability to recall important personal information that is too severe to be explained by ordinary forgetfulness

The illness is not the result of the direct physiological effects of a substance (for example, blackouts or other abnormal behavior during alcohol or other drug intoxication) or a general medical condition (for example, seizures). In children, the symptoms are not caused by imaginary playmates or other fantasy play.

Professionals usually gather facts about the individual's childhood and ask questions to explore whether the symptoms that the client is suffering from are not better accounted for by another mental disorder, dissociative or otherwise. Other types of dissociative disorders include depersonalization disorder (feeling detached from themselves or surroundings), dissociative amnesia (memory problems associated with a traumatic experience), dissociative fugue (abandonment of familiar surroundings and memory lapse for the past), and dissociative disorder, not otherwise specified (episodes of dissociation that do not qualify for one of the specific dissociative disorders just described). As part of the assessment, mental health professionals also usually ask about other mental conditions and ensure that the person has recently received a comprehensive physical examination so that any physical conditions that may mimic symptoms of DID are identified and addressed.

Dissociation, a major symptom of DID, is known to occur in a number of other mental illnesses. For example, an individual with this disorder may seek to relieve overwhelming memories of trauma by engaging in the self-mutilation that tends to be found in those with borderline personality disorder. Also, feelings and behaviors that may appear to be caused by dissociation, but are not, make it all the more difficult to distinguish DID from other conditions. Somatization disorder, psychogenic amnesia, psychogenic fugue, conversion disorder, and schizophrenia are just a few such disorders. Rape and other adult trauma victims have been found to be quite vulnerable to developing dissociative symptoms. The controversy about whether DID exists, as well as the overlap of symptoms it has with a number of other conditions, sometimes results in misdiagnosis.

Symptoms of some other mental disorders may be mistaken for dissociation. The wide changes in emotions associated with bipolar disorder or experienced by individuals with narcissistic personality disorder when triggered by minor slights are two such examples. Blackouts that can be related to substance abuse or dependence are other instances of an individual being unaware of his or her surroundings that mimics dissociation.

DID often co-occurs with other emotional conditions, including posttraumatic stress disorder (PTSD), borderline personality disorder (BPD), and a number of other personality disorders, as well as conversion disorder. DID is sometimes feigned by individuals who may be seeking attention, as in Munchausen's syndrome. It has also been appropriately diagnosed as well as feigned in individuals involved in the criminal justice and civil or family court systems (for example, forensic cases). Adding to the diagnostic difficulty is that people like pedophiles and other sex offenders, as well as people with antisocial personality disorder, may legally stand to gain from having DID. While some of those individuals may feign the diagnosis in an effort to benefit legally, others genuinely suffer from significant dissociative symptoms, as well as full-blown DID. In cases where there may be an ulterior motive for being diagnosed with DID, studies show that using a structured interview tool may be the best way to determine if the person truly suffers from this condition.

What are the treatment methods for dissociative identity disorder?

Psychotherapy is generally considered to be the main component of treatment for dissociative identity disorder. In treating individuals with DID, therapists usually try to help clients improve their relationships with others and to experience feelings they have not felt comfortable being in touch with or openly expressing in the past. This is carefully paced in order to prevent the person with DID from becoming overwhelmed by anxiety, risking a figurative repetition of their traumatic past being inflicted by those very strong emotions. Mental health professionals also often guide clients in finding a way to have each aspect of them coexist, and work together, as well as developing crisis-prevention techniques and finding ways of coping with memory lapses that occur during times of dissociation. The goal of achieving a more peaceful coexistence of the person's multiple personalities is quite different than the reintegration of all those aspects into just one identity state. While reintegration used to be the goal of psychotherapy, it has frequently been found to leave individuals with DID feeling as if the goal of the practitioner is to get rid of, or "kill," parts of them.

Hypnosis is sometimes used to help increase the information that the person with DID has about their symptoms/identity states, thereby increasing the control they have over those states when they change from one personality state to another. That is said to occur by enhancing the communication that each aspect of the person's identity has with the others. In this age of insurance companies regulating the health care that most Americans receive, having time-limited, multiple periods of psychotherapy rather than intensive long-term care provides what may be another effective treatment option for people with DID.

Eye movement desensitization and reprocessing (EMDR), a treatment method that integrates traumatic memories with the patient's own resources, is being increasingly used in the treatment of people with dissociative identity disorder. It has been found to result in enhanced information processing and healing.

Medications are often used to address the many other mental health conditions that individuals with DID tend to have, like depression, severe anxiety, anger, and impulse-control problems. However, particular caution is appropriate when treating people with DID with medications because any effects they may experience, good or bad, may cause the sufferer of DID to feel like they are being controlled, and therefore traumatized yet again. As DID is often associated with episodes of severe depression, electroconvulsive therapy (ECT) can be a viable treatment when the combination of psychotherapy and medication does not result in adequate relief of symptoms.

What is the prognosis for dissociative identity disorder?

Research indicates that people with dissociative identity disorder have their best opportunity for living a well-adjusted life if they receive comprehensive treatment for their multiple symptoms. However, differences in how practitioners diagnose and treat this illness make it difficult to quantify outcomes.

What are complications of dissociative identity disorder?

As with other mental health conditions, the prognosis for people with DID becomes much less optimistic if not appropriately treated. Individuals with a history of being sexually abused, including those who go on to develop dissociative identity disorder, are vulnerable to abusing alcohol or other substances as a negative way of coping with their victimization. People with DID are also at risk for attempting suicide more than once. Violent behavior has a high level of association with dissociation as well. Other debilitating outcomes of DID, like that of other severe chronic mental illnesses, include inability to obtain and maintain employment, poor relationships with others, and therefore overall lower productivity and quality of life.

How can dissociative identity disorder be prevented?

Given that the origin of dissociative identity disorder in the majority of individuals remains related to exposure to traumatic events, prevention for this disorder primarily involves minimizing the exposure to traumatic events, as well as helping survivors of trauma come to terms with what they have been through in a healthy way.